JMJ Marist Brothers

Notre Dame of Marbel University

College of Arts and Sciences – Nursing Department
Alunan Avenue, Koronadal City, South Cotabato

NCM – N 117 B CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR

PSYCHIATRIC CASE NO. 3: DISSOCIATIVE IDENTITY DISORDER

SCENARIO:

Introduction

G.Y., a 20-year-old male, was transferred from the military hospital to an intensive
psychiatric ward due to complaints of episodic violent behaviors toward fellow soldiers
and changes in character and personality, which began at the onset of his military
service two months earlier.

Past Health History

Four months prior to admission, the patient returned home after six years of studying
abroad. His parents reported that the patient's behaviors differed from those of a visit
one year prior, when he was shy and timid. After his return to the Philippines, the patient
appeared very confident and told his parents he would fare well in his military service. In
addition, he was very forgetful, often losing his belongings. The patient was on one
occasion found by police in an alley far from his house, and he could not remember how
he got there. Shortly after these incidents, the patient reported to the army for
mandatory military service. At training camp, he seemed passionate and outgoing, quite
different from his usual identity.

On several occasions, he only spoke English, which is not his native language. One
incident involved a violent assault, in which he injured another soldier. Alarmed by his
emergent psychiatric problems, the military sent him to a psychiatric unit, where the
staffs observed several different personalities. After one week, the military psychiatric
staff decided to send him to a specialized civilian psychiatric hospital.

Present Health History

During the course of hospitalization, seven alters were observed. The main host was
very quiet and intimidated. John, an arrogant and uncooperative personality speaking
only English, appeared on several occasions during the interviews conveying some
suicidal ideations at times. Another violent alter appeared twice when the patient
thought of his childhood. During the transition to the violent alter, the patient broke a
window with his fist and tried to hit his physician. Another alter named Cho appeared
once. Cho introduced himself as the patient's story watcher and teller. Cho insisted he
knew the host and other alters very well. He spoke both Filipino and English, depicting
the host as a "pity thing," the violent as a "thirsty killer," and the arrogant alter, John, as
a "shit." While talking, Cho produced automatic writing with his left hand, of which he did
not seem to be aware. We observed an additional three alters including a five-year-old
boy, a mother-like personality, and a "metro-sexual swagger" alter. Cho was aware of
the transition processes and he emphasized that there were more identities, although
they were not observed during the hospitalization.

Laboratory tests including drug use screening and brain computerized tomography (CT)
scan indicated no abnormalities of the host ego. Electrocardiogram (ECG) indicated
"normal sinus rhythm." Interestingly, when retested as an alter, "Cho", the ECG
indicated a "right bundle branch block." Cognitive impairment or malingering was ruled
out through a full psychological battery, and no other psychiatric comorbidities were
found. A structured clinical interview for DSM-V dissociative disorder (SCID-D)
confirmed the current diagnosis of DID.

In the Structured Clinical Interview for DSM-V Dissociative Disorders (SCID-D), the
patient scored the severe category in amnesia, depersonalization, derealization, and
identity confusion and identity alteration with additional fulfillment of mood change, age
regression, and internal voice. He demonstrated the existence of alternate personalities
with distinct names, ages, and character traits. Each alter took complete control of the
patient's behavior, resulting in such occurrences as finding himself in a strange place,
losing or discovering possessions in spots different from where he remembered leaving
them, and speaking English. The patient also reported total amnesia during the
domination of an alter.

The patient reported repeated childhood physical and emotional abuse and neglect by
his parents. Each time he accessed these memories, he became agitated and
transitioned to a violent alter.

The treatment focused on stabilization, including affect regulation, grounding exercise

and imagery techniques. Part of the management done to him is the administration of
anxiolytics, Alprazolam (Xanax) and antidepressant, Sertraline (Zoloft). Treatment made
him more grounded and relaxed and decreased the frequency of alter emergence,
particularly the violent alter. The stabilization was noted after three (3) weeks of
intensive management.

After one month of hospitalization, the patient is ready for discharge.

EXPOSURE: JUNE 14, 2021, Shift 7AM to 3PM

Routine:

1. Checking of Attendance and Paraphernalia

2. Preconference
3. Endorsement
4. Morning Rounds
5. Activities of Daily Living (ADLs)
6. Medication
7. Clinical Encounter/ Therapy

7 AM – Endorsement

“Good morning, endorsement! Endorsing Patient G.Y., 20 years old, came in due
to episodic violent behaviors toward others and changes in character and personality;
with an admitting diagnosis of Dissociative Identity Disorder; on Diet As Tolerated
(DAT), no caffeinated foods and drinks, no sodas and chocolate and chocolate-
containing foods and drinks. Suicide and Safety Precaution must be observed.”

The following patient care plan information are available:

Name: G.Y. Patient No: 21-05380

Age: 20 y.o. Room: Psych Ward
Sex: M Doctor: Dr. K.D.J.
Weight: 60 kg

Vital Signs for 7 AM: BP: 110/80, CR: 80 bpm, RR: 19 cpm, Temp: 36.9, SPO2: 99%

VS q 4 hours No IVF
I&O q shift Diet: Diet as Tolerated

Labs and Diagnostics: Special Endorsements: Routine medications:

⮚ Complete Blood ⮚ Suicide and Safety ⮚ Sertraline (Zoloft)
Count (CBC) Precaution 50 mg 1 tab PO OD
done ⮚ Strictly no caffeinated PC @ 8 AM
⮚ Urinalysis done foods and drinks, ⮚ Alprazolam (Xanax)
⮚ Chest X-ray done sodas, chocolate and 0.5 mg PO TID
⮚ CT Scan done chocolate-containing
⮚ ECG done foods and drinks
7:30-8:00 AM – Morning Rounds, Vital Signs Taking

Received patient, sitting on bed, awake and oriented. No IVF attached.

Vital Signs: BP: 110/80, CR: 78 bpm, RR: 20 cpm, Temp: 36.9, SPO2: 98%

8:00- 9:30AM – Activities of Daily Living (ADLs)

The patient appeared quiet and conformant to instructions. Responds to questions and
instructions in Filipino language. He willingly performed the expected morning routine
such as the physical exercise and attending the daily psychotherapy activity. Due
medication was administered.

10AM – Assessment and Interaction

During the nurse-patient interaction, patient G.Y., the main host was very quiet and
intimidated. As the conversation progressed, G.Y stated that one of his alters, John,
wants to come out and talk. When recognized, the alter “John”, spoke in an arrogant
manner who seems to appear uncooperative and speaking only English and has
conveyed that at times, suicidal ideations were thought of by him . Once in a while, this
alter appeared on several occasions during the interview. When the conversation
delved into the patient’s childhood, another violent alter appeared twice. During the
transition to the violent alter, the patient slammed his journal on the floor and made a
fist and appeared angry. The interaction continued with another alter named Cho who
introduced himself as the patient's story watcher and teller. Cho insisted he knew G.Y,
the host, and other alters very well. He spoke both Filipino and English and describes
the host as a "poor thing," the violent as a "thirsty killer," and the arrogant alter, John, as
a "shit." While talking, Cho produced automatic writing with his left hand, of which he did
not seem to be aware. When the alter shifted back to the host, the nurse asked him to
try writing what he feels at the moment in his journal. It was then noted that the host,
G.Y. is right-handed. In the progress of the conversation, it was observed that additional
three alters are also present which includes a five-year-old boy, a mother-like
personality, and a "metro-sexual swagger" alter. Cho was aware of the transition
processes and he emphasized that there were more identities, although they were not
observed during the interaction and the hospitalization. Furthermore, journal was
viewed which revealed various handwriting for each alter with varied emotions reflected
in the writings.

11:30 AM-12:00 PM
● Patient was seated quietly, with rapid eye movements looking around the area.
Few seconds thereafter, he started pacing and talked endlessly in English and
started cursing some names. Upon manifesting such behavior, the patient was
brought back to his room and was asked if his vitals can be checked. The patient
agreed and Vital Signs taken were as follows:
BP: 130/90, CR: 95 bpm, RR: 25 cpm, Temp: 37.2, SPO 2: 98%
● The resident psychologist talked to the patient to process his current status.
 ● Patient’s due medication administered thereafter the session with the
psychologist.
Requirements:

1. Prioritize a nursing problem presented in the case of patient G.Y., and make a
nurse’s notes using the SOAPIE format.

2. Using the DSM-V, identify the diagnostic criteria for Dissociative Identity Disorder
manifested by patient G.Y. and specify the objective and subjective cues that
point out to the identified criteria.

3. Make one (1) Nursing Care Plan (NCP) for Dissociative Identity Disorder based
on the cues stipulated in the case scenario.

4. Make one (1) drug study: Sertraline (Zoloft) (focus to the relevance of these
drugs in the case).

5. Group Task: Device a psychotherapy (minor and major activities) that fits for a
patient with Dissociative Identity Disorder. Use the given format for minor and
major activities for this requirement.